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Interdisciplinary Models of HIV Care Jeremy Holman, PhD Lisa Hirschhorn, MD, MPH 2012 Ryan White Grantee Meeting Workshop November 27, 2012

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Disclosures This continuing education activity is managed and accredited by Professional Education Service Group. The information presented in this activity represents the opinion of the author(s) or faculty. Neither PESG, nor any accrediting organization, endorses any commercial products displayed or mentioned in conjunction with this activity. Commercial support was not received for this activity. Presenters Jeremy Holman, PhD; Lisa Hirschhorn, MD, MPH; Marwan Hassad, MD; Robert Murayama, MD; and Kathy Gaddis, MSW, LCSW, PIP have no financial interest or relationships to disclose.

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Learning Objectives At the conclusion of this workshop, participants will be able to Identify key factors that make interdisciplinary HIV care models most effective Understand how interdisciplinary HIV care models have been implemented in a range of care settings, including common elements, challenges, and how these models might be adapted for their settings Understand the implications of health care reform for interdisciplinary HIV care and the models of care which they have in place

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Workshop Structure Summary of results of HRSA/HAB study conducted by JSI Comments from the field from participating grantees Discussion with audience

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Study Background Background HRSA/HAB interested in understanding essential factors of successful interdisciplinary models HIV care Affordable care act (ACA), other health care reform, expanded testing, and aging client population require innovative approaches Questions What services are well suited for interdisciplinary models? What characteristics and skills make these models successful? Methods Literature review Expert consultations Site visits with Ryan White Program grantees

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Literature Review: Methods Included : English-language literature since 1995 Medical and nursing conferences, 2009 - 2011 222 articles and 16 conference abstracts identified 110 reviewed 28 abstracted for analysis 21 programs included analysis 9 medical-focused 12 behavioral health-focused

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Literature Review: Findings Majority of programs relied on federal funding 10 of 21 had RWHAP support Models that integrate specialty medical and behavior health services appear most promising Case management or other care coordination services critical Effective EHRs facilitate care coordination and communication Evaluation data were process focused and not standardized Behavioral health programs had more rigorous study designs, and results supported positive outcomes Cost and finance data were lacking for most programs No programs with negative outcomes were identified

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Expert Consultations: Methods Phone interviews with 8 key informants Providers, managers, PLWH Focus on: Essential program components for success in HIV care Impact on care setting and targeted population(s) Core staff competencies needed for interdisciplinary care Potential barriers to implementation Supportive management structures Defining and measuring success, quality, and cost effectiveness Benefits to and potential concerns of patients

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Expert Consultations: Themes Ideal model is: co-located (if not, then closely coordinated) client-centered HIV medical and related services, delivered by multidisciplinary team of primary and HIV care providers (MDs, NPs and PAs), behavioral health professionals, social workers, case managers/care coordinators, other selected specialists. Communication, cross training, team decision making, and solid leadership critical to success. Financing is a significant challenge and potential barrier. Quality routinely measured Information on cost and cost-effectiveness is lacking.

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Grantee Site Visits: Methods Identified 12 potential RWHAP grantees Based on literature review, consultations, team member experience, and other recommendations Selected nine for site visits Reflected geographic, client, and programmatic diversity Conducted 1-2 day site visits, May July 2012 Discussions with leadership, staff, and consumers

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Harborview Medical Center AIDS Arms, Peabody Health Center Kansas City Free Clinic UAB 1917 Clinic Family & Medical Counseling Services Community Health Center, Inc. APICHA CHC Philadelphia Fight Chatham County Health Dept. CARE Program Grantee Site Visits

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Site Visits: Findings Context Local and historic context is important, and may limit replicability Models developed over time, in response to needs of community and patients Began either as ASO/CBO or clinical care site, and evolved into current model

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Site Visits: Findings Models of Care Most were patient-centered, one-stop shop Variations in level of physician vs. nurse/NP-centered Case managers served critical roles on team Ancillary services must remain integrated into the model and coordinated with clinical services Availability of onsite specialty services varied External referrals presented challenges Culture of program as important as components

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Site Visits: Findings Leadership, Staffing, Team Leadership and team building is essential to model Staffing included core medical team, supplemented by staff from other disciplines with varying credentials Team meetings are critical for communication and effective care

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Site Visits: Findings EHRs Functional EHR are critical tool for effective implementation of models Among sites with EHRs, staff access and inclusion of different components (e.g., behavioral health, case management) varied Quality Strong focus on quality, integrated into model

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Site Visits: Findings Fiscal and Sustainability RWHAP is essential, given clients socio-economic status Enrollment and eligibility requirements are challenging and affect consistency of services There was concern about ACA and focus on CHCs to provide HIV care There were challenges related to Medicaid eligibility, coverage, and reimbursement in many states

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Site Visits: Findings Consumer Perspectives Strong support for models, esp. one-stop-shop Case management services are critical component Facilitators: Expanded hours, walk-in appointments, and multi-lingual staff Barriers: Clinic growth increasing wait times, transportation, stigma, bad experiences with some service providers (e.g., phlebotomists)

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Insights from Grantees Community Health Center, Inc. Adaptation and implementation of ECHO model APICHA Community Health Center Evolution of ASO to clinical care site 1917 Clinic, University of Alabama Role of the interdisciplinary team

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November 27, 2012 Marwan Haddad, MD, MPH, AAHIVS Medical Director for HIV, HCV, and Buprenorphine Services Community Health Center Inc., Connecticut

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Our Vision: Since 1972, Community Health Center, Inc. has been building a world- class primary health care system committed to caring for underserved and uninsured populations and focused on improving health outcomes, as well as building healthy communities. CHC Inc. Profile: Founding Year - 1972 Primary Care Hubs 13 No. of Service Locations - 218 Licensed SBHC locations 24 Organization Staff 500 Providers (all) 170 Patient Number 130,000 Healthcare visits 410,000/yr Three Foundational Pillars Clinical Excellence Research & Development Training the Next Generation Innovations Meaningful Use Stage 1 Integrated primary care disciplines Fully integrated EHR Patient portal and HIE Extensive school-based care system Wherever You Are Health Care Centering Pregnancy model Residency training for nurse practitioners New residency training for psychologists Community Health Center, Inc.

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Project ECHO TM Evidence-based: ECHO TM Model Patient Specialist PCP Current model: Specialist Patient

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Potential Benefits & Expected Outcomes of Implementation of Project ECHO For Patients Increased access to treatment options for underserved patients More patients initiating treatments More patients completing treatments Cost effective careavoid excessive testing and travel Prevent cost of untreated disease More treatment options at their medical home For Providers Self-efficacy increases Improving profession satisfaction and retention Workforce training and force multiplier Integration of public health into treatment paradigm

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Implementation Faculty Specialist Recruitment Replication Visit Joining Project ECHO New Mexico Technical Capability PCP recruitment Administrative Support Funding

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Successes Successful replication of Project ECHO at a large, multisite FQHC Full EHR integration/paperless system Multipoint videoconferencing technology Improved knowledge and self efficacy for PCPs Multiple HIV and HCV patients being managed by their PCPs 84 patients managed (55 HCV and 29 HIV) HIV: 100% on ARVs 83% stayed on same ARVs, 10% required change, 7% new starts HCV: 9% started treatment

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Challenges Recruitment Provider Patient Administrative Time/Productivity IT Agency Buy-in Care Management Provider/Patient Readiness Ancillary Services Feedback

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Robert Murayama, MD, MPH Chief Medical Officer

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APICHAs Mission Statement To improve the health of our community and to increase access to comprehensive primary care, preventive health services, mental health and supportive services. We are committed to excellence and to providing culturally competent services that enhance the quality of life. APICHA advocates for and provides a welcoming environment for underserved and vulnerable people, especially Asians & Pacific Islanders, the LGBT community and individuals living with and affected by HIV/AIDS. (revised 2010)

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Evolution of APICHA FQHC Look Alike Trans Health Care LGBT Primary Care HIV Primary Care HIV Test Bilingual CM Outre ach 1996 RW SPNS 2012 2010 2009 2000 2001 RW EIS 1989

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APICHA Community Health Center Medical Home Model Enabling Services Care Management Ancillary Services Prevention Health promotion Disease prevention Medical Services Mental Health Policy Advocacy Community Engagement Community- based research Partnerships

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How to sustain multidisciplinary work? RW-C EIS Program RW-A funded Care Coordination program Medicaid funded Health Home (Care Manager) Integrating HIV prevention work with clinic services FQHC Look Alike designation for better reimbursement and enrolment to various Medicaid managed care plan Plan to apply for FQHC New Access Point

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Key to Success Morning Huddle with PCP, clinic support staff, CMs, MH Weekly multidisciplinary meeting Monthly case conference: MH, CMs, PCP MH and PCP meeting twice a month Use of EMR (APICHA CHC is Patient Centered Medical Home Level 3) Participation of HIV prevention staff at multidisciplinary meeting to ensure access to care for HIV positive and very high risk.

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Success Expanding HIV model of care to other population and sustaining services to HIV infected and high risk patients Volume increase 99 HIV patients in 2007 to 305 HIV patients in 2011 Quality indicators (HIVQUAL) 83.3% of patients are retained in care 93.3% of patients are on ARV Viral load suppression: 81.4% of those on ARV

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Challenges Current FQHC model does not recognize LGBT and HIV as special population HIV Medical Care is not recognized as Specialty Care. The reimbursement rate is low (same as Primary Care) although HIV requires more complicated management than general primary care Staff re-orientation and training is on going

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2,100 Patients 34 Medical Providers 39 Clinic Staff 7 Dental Staff 12 Research Staff

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Patient Attending Physician Nurse Practioner or ID Fellow Registered Nurse Social Worker

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Social Work Linkage to Care Medication Acquisition Case Management Adherence Nursing Manage Clinic Flow Triage Symptom Analysis Front Office Registration Phone Triage Scheduling Courier Providers Infectious Disease Specialists Endocrinology, Palliative, Psychiatry, Dermatology, Neurology, Nephrology Mental Health Counseling Case Management Substance Abuse Treatment Oral Health Care Restorative Preventative Complex Endodontics Education Prevention Outreach Testing Training for Staff and Patients Research ACTG Clinical Trials Behavioral Science Trials Pharmaceutical Trials IT (Technology) Desktop Support Network Support Clinical Informatics Medical Records Release of Protected Information Cross Functionality

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Management that appreciates EVERY role Staff meetings with time for public appreciation Gold Star Clinics Staff meetings where the monthly accomplishments of each team is recognized Leadership modeling stepping out of assigned role to pitch in Reviewing Outcome of Quality Indicators with staff

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77% of patients have a Viral Load 500, 97% are on antiretroviral therapy For patients with CD4